FORMS 1) PAR Q & YOU:

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1 Personal Training New Client Registration Congratulations on taking the first step to healthier and better you! The certified trainers are screened by the OCR staff to ensure a high quality of service and a commitment to the wellness philosophy. By signing, you agree to the policies and procedures set forth by the Vanderbilt Office of Campus Recreation. SIGN UP 1) Fill out the registration forms. 2) Pay for your sessions in the VRWC Office of Campus Recreation or at the Welcome Desk during business hours. Payment is due at registration. Cash, check, major credit cards, and Commodore card accepted. All sessions must be paid for in advance of training. 3) A Personal Trainer will contact you to set up your appointment. * You may either request a trainer or you will be matched with one that will best suit your needs. If you request a trainer, we will make every effort to match you with that trainer. If that is not possible, you will be matched with the one that best suits your needs. FORMS 1) PAR Q & YOU: Assessment of any health concerns that may limit your exercise capabilities. 2) HEALTH CARE PROVIDER S CONSENT FORM: Use only if you answered YES to any of the PAR-Q questions. 3) CONSENT AND ASSUMPTION OF RISK 4) MEDICAL AND HEALTH HISTORY QUESTIONNAIRE 5) PERSONAL TRAINING FOR MINORS: Use only if you are the parent/legal guardian registering a minor for personal training. COST One on One.$60.00 per hour Small Group $40/hour/person *Individuals wanting to do group training must be at similar or equal fitness levels-determined by the Personal Trainer. *Cancellations: A client wishing to cancel or reschedule a session should contact their trainer immediately. Failure to do so 24 hours prior to the scheduled appointment time is subject to forfeiture of the training session, which is why it is important to contact your trainer. We understand there are unpredictable circumstances and we value your and our time, so stay courteous Nashville! *Training times run approximately one hour. Clients and trainers do not have priority over equipment in the Fitness Center. All members should demonstrate the usual courtesy when waiting for equipment by allowing people to work in and so on. Relay any concerns to the Fitness Center or VRWC staff. Thank you for your interest in our program. Jennifer Ray Wellness Coordinator Vanderbilt Recreation and Wellness Center Phone: jennifer.e.ray@vanderbilt.edu Office use only: Client = # of Sess. Rate Total Fee Receipt # Payment Method: Credit Card Check Cash Commodore Card 1

2 PAR Q & YOU Regular activity is fun and healthy as well as very safe for most people. However, some people should check with their doctor before they start becoming much more physically active. Start by answering the questions in the box below. If you are between the ages of 15 and 69, the PAR-Q will tell you if you should check with your doctor before you start. If you are over 69 years of age, and you are not regularly very active, check with your doctor. Common sense is your best guide when you answer these questions. Please read the questions carefully and answer each one honestly: check YES or NO for each. Yes/No 1. Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor? 2. Do you feel pain in your chest when you do physical activity? 3. In the past month, have you had chest pain when you were not doing physical activity? 4. Do you lose your balance because of dizziness or do you ever lose consciousness? 5. Do you have a bone or joint problem that could be made worse by a change in your physical activity? 6. Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or heart condition? 7. Do you know of any reason you should not do physical activity? If you answered: NO to all questions: If you answered NO honestly to all PAR-Q questions, you can be reasonably sure that you can: Start becoming much more physically active- begin slowly and build up gradually. This is the safest and easiest way to go. Take part in a fitness assessment or a personalized exercise regimen. YES to one or more questions: Talk to your doctor BEFORE you start becoming more physically active or BEFORE you have a fitness assessment/personal training. You may be able to do any activity you want as long as you start slowly and build up gradually. Or, you may need to restrict your activities to those which are safe for you. Talk with your doctor about the kinds of activities you wish to participate in and follow his/her advice. *If you are not feeling well because of a temporary illness such as a cold or fever wait until you feel better; or if you are or may be pregnant talk to your doctor before you start becoming more active. * If your health changes so that you then answer YES to any of the above questions, tell your fitness or health professional. Ask whether you should change your physical activity plan. PLEASE NOTE: If you answered YES to any of the PAR-Q questions, a HEALTH CARE PROVIDER S CONSENT FORM must be submitted prior to receiving a fitness assessment or any prescriptive fitness program. If you would like the form faxed to your healthcare provider (local only), please contact Jennifer Ray, Vanderbilt Recreation & Wellness Center, Informed Use of the PAR Q: The Office of Campus Recreation, Vanderbilt University and their agents assume no liability for persons who undertake physical activity under the direction of professional staff or within the Vanderbilt Recreation and Wellness Center. If in doubt after completing this questionnaire, consult your doctor prior to physical activity. Note: If the PAR Q is being given to a person before he or she participates in a physical activity program or a fitness appraisal, this section must be used for legal or administrative purposes. I have read, understood and completed this questionnaire. Any questions I had were answered to my full satisfaction. Client Name (print) Signature Date If signing on behalf of a minor: Parent/Legal Guardian Name (print) Signature 2

3 HEALTH CARE PROVIDER S CONSENT FORM VANDERBILT OFFICE OF CAMPUS RECREATION REQUIRED ONLY IF YOU ANSWERED YES TO ONE OF THE PAR-Q QUESTIONS Client s request for clearance to participate in a Fitness Assessment and Personal Trainer Exercise Program. Dear Dr. : Your patient,, has expressed interest in beginning a supervised exercise program at Vanderbilt University Office of Campus Recreation, with a Personal Trainer. This program may include a series of fitness assessments including any or all of the following procedures: a submaxmimal aerobic capacity test, a body fat estimate, flexibility test(s), and a battery of muscle strength and endurance measures. The nature of both the exercise testing and programming will depend on your patient s (1) stated health history as indicated from a completed health risk appraisal form, (2) stated fitness goals, and (3) feedback from his/her health care providers. All programming is done in accordance with the guidelines of the American College of Sports Medicine, and all trainers are CPR and Safety-First Aid certified. By completing this consent form, you are not assuming any responsibility for our administration of the fitness tests and/or exercise programs. If, however, you are aware of any reasons, medical or otherwise, which might impact or be impacted by participation in an exercise program or from exercise testing, or are aware of any specific precautions and/or contradictions and/or guidelines which should be considered by the Personal Trainer, please use the spaces below to provide sufficient detail. If you have any questions regarding these matters, please call Jennifer Ray, Activities Coordinator of Wellness & Fitness, at (615) Any other questions or concerns should be directed to your patient. (Place your initials beside the appropriate statement(s) and complete those which apply.) I know of no reason(s) why the above named patient should not participate in any of the fitness tests or exercise programming. To the best of my current knowledge, I believe my patient, is able to participate in the exercise testing and programming with the following restrictions and/or recommendations: I recommend that my patient does NOT participate in any exercise testing or programming until such time as I have consulted with him/her again. Health Care Provider s Signature Date Please Print Name Here Phone Number Please return form to patient or fax to: Vanderbilt Personal Training Attn: Jennifer Ray Fax:

4 CONSENT AND ASSUMPTION OF RISK PERSONAL TRAINING VANDERBILT OFFICE OF CAMPUS RECREATION I,, desire to use the services of a Personal Fitness Trainer at the Vanderbilt Recreation and Wellness Center. I understand that working with a Personal Trainer will involve a physical fitness program which may include aerobic activities (such as treadmill, walking/running, bicycle riding, rowing machine exercise, group aerobic activity, swimming, and other related activities), calisthenics and weight lifting to improve muscular strength and endurance, and flexibility exercises to improve joint range of motion. I understand that the reaction of the heart, lungs, and blood vessel system to such exercise cannot always be predicted with accuracy. I know that during or following exercise there is a risk that I may experience abnormal blood pressure or heart rate, ineffective functioning of the heart, and in rare instances, heart attacks. Use of the weight lifting equipment and engaging in heavy body calisthenics can lead to musculoskeletal strains, pain and injury. I also understand that a program of a regular exercise for the heart, lungs, muscles and joints has many associated benefits. These may include a decrease in body fat and risk of heart disease as well as improvement in blood fats, blood pressure, and psychological function. The amount and degree of benefits experienced will be relative to personal adherence of an exercise program based on prescribed amounts of intensity, duration, frequency, progression and types of activity. I have read the above information and I understand the potential risks and benefits of working with a Personal Trainer and I voluntarily agree to assume such risks. Further, in consideration of the Vanderbilt Recreation and Wellness Center providing me with a Personal Trainer, I hereby release and hold harmless the Office of Campus Recreation, Vanderbilt University, and all professional staff from any claims or causes of action of any kind. Client Name (print) Date Client Signature If signing on behalf of a minor: Parent/Legal Guardian Name (print) Signature 4

5 MEDICAL AND HEALTH HISTORY QUESTIONNAIRE VANDERBILT OFFICE OF CAMPUS RECREATION Name (Client) Birth Date Campus Box Primary Address City State Zip code Phone Number address Name of Parent/Legal Guardian (if client is a minor) Phone In Case of Emergency Contact: Phone: Please check if you would like to be matched with a training group. We will send you more information about this program. MEDICATIONS: (Include any over the counter medications or other drugs you are taking currently) NAME DOSAGE PURPOSE FOR HOW LONG? Please list any current problems/chronic conditions or past orthopedic surgeries: NECK SHOULDER/ CLAVICLE ARM/ELBOW WRIST/HAND RIBS/CHEST SPINE PELVIS THIGH/HIPS KNEE/PATELLA LOWER LEG ANKLE FOOT/TOES If you have checked, any of the above please explain: ARE THERE ANY SPORTS OR ACTIVITIES IN WHICH YOU WOULD LIKE TO BE ABLE TO PARTICIPATE OR TO IMPROVE? ARE THERE ANY ACTIVITIES THAT YOU DO NOT LIKE TO PARTICIPATE IN? FITNESS GOALS IMPROVE STRENGTH IMPROVE FLEXIBILITY IMPROVE CARDIOVASCULAR FITNESS IMPROVE MUSCLE TONE IMPROVE DIET/ EATING HABITS LOSE WEIGHT/ INCHES GAIN WEIGHT/ INCHES PREVENT INJURY IMPROVE EXERCISE/HEALTH HABITS REHABILITATE INJURY ADDITIONAL GOALS please list below in comments section Comments: HOURS OF AVAILABILITY/PREFERENCE MON TUES WED THURS FRI SAT SUN 7am 8am 9am 10am 11am 12pm 1pm 2pm 3pm 4pm 5pm 6pm 7pm 8pm 5

6 Personal Training for Minors Vanderbilt Recreation and Wellness Center Thank you for your interest in personal training for your child. As part of offering this service to minors, Vanderbilt has put the following notices and procedures in place: Parental permission is required for a minor to participate in personal training. Minors must be at least ten years old to participate in personal training and at least eight years old to participate in boxing lessons. All minors under the age of 16 must have a parent remain on site during personal training. Talk with the trainer about the training goals for your child and include your child in the discussion. Sessions are often in public workout areas, but trainers may be 1 on 1 with the trainee during a session in a room within the facility or on the athletic fields. Parents are welcome to observe the training at any time but we ask that you refrain from coaching or correcting your child during the session. It is expected your child will remain respectful to the trainer at all times and follow all advised rules of safety on and around any equipment. If the trainee does not follow this expectation, the training sessions may be discontinued. Personal training for children is different than adult sessions; what may look like a game may be teaching your child a valuable skill. For any concerns, the Recreation Center front desk staff can direct you to the manager on duty. Vanderbilt wants children to feel safe and be safe in all its sponsored activities. Vanderbilt personnel adhere to Tennessee state law on mandatory child abuse reporting. If you have reason to believe abuse or inappropriate behavior has occurred concerning a minor participating in a Vanderbilt University program, please consult the program director, or Risk Management ( ), or report via the Vanderbilt hotline at The Tennessee Child Abuse reporting hotline number is We look forward to assisting you and your child in meeting your wellness and fitness needs. For any questions about this document, please contact: Jennifer Ray Wellness Coordinator Vanderbilt Recreation and Wellness Center Phone: My signature below also indicates my receipt and understanding of the attached Personal Training for Minors document Parent/Legal Guardian Name (print) Date Signature 6